Benevolence Assistance Request Form

Criteria for considering your request:

If No, how did you hear about Spirit Life Church of Jesus Christ?

I release the Spirit Life Church of Jesus Christ Benevolence Team to the following:(acknowledge all with your initials)

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Marital Status

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

List all Individuals sharing your household #1.

First NameLast Name

Relationship

Date of Birth

Date

Age

Monthly Income

Name #2

First NameLast Name

Relationship

Date of Birth

Date

Age

Monthly Income

Name #3

First NameLast Name

Relationship

Date

Age

Monthly Income

Name #4

First NameLast Name

Relationship

Date of Birth

Date

Age

Monthly Income

Name #5

First NameLast Name

Relationship

Date of Birth

Date

Age

Monthly Income

Additional Household Members (if applicable)

Please list your specific request:

Amount Requested:

Date Funds are Needed:

Date

Briefly, what events led to your needing assistance? (Be clear and summarize your information)

Present/Most Recent Employer

Position & Job Description:

Name of Supervisor

Employees Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employees Phone:

Please enter a valid phone number.Format: (000) 000-0000.

Dates of Employment:

If unemployed, for how long?

Are you currently seeking employment?

If no, why not?

If yes, what steps are you taking to seek active employment?

Present/Most Recent Employer:

Position & Job Description:

Supervisor Name:

First NameLast Name

Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Dates of Employment

If unemployed how long?

Are you currently seeking employment?

If not, why not?

If yes, what steps are you taking to seek active employment?

Housing/Car:

How long at present address?

Landlord or Mortgage Company:

Landlord/Mortgage Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Previous Landlord/Mortgage Company:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How long did you live there & why did you move?

Do you have access to a car?

If yes, please check all that apply:

If owned or leased what is the Year, Make & Model of Vehicle?

If paying payments, how much until the car is paid off?

How many cars are in your household?

Are you a tithe payer to Spirit Life Church of Jesus Christ?

If yes, how long?

Have you seen a financial counselor in the last 6 months?

If yes, with whom?

Have you contacted anyone else for assistance within the last six months?

If yes, with whom?

If so, specify:

Are any of the above assisting with your needs?

If yes, what amount?

If no, why not?

Do you have a budget?

Have you requested or received assistance from Spirit Life Church of Jesus Christ before?

If so, when did you make the request and what amount was received?

Reference #1

First NameLast Name

Reference #1

Please enter a valid phone number.Format: (000) 000-0000.

Reference #2

First NameLast Name

Reference #2

Please enter a valid phone number.Format: (000) 000-0000.

Reference #3

First NameLast Name

Reference #3

Please enter a valid phone number.Format: (000) 000-0000.

Ministry Contact Person (if you volunteer at Spirit Life Church of Jesus Christ)

First NameLast Name

Ministry Contact Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Please provide any additional information, if applicable.

Applicant's Monthly Income

Spouse's Monthly Income

Child/Spousal Support

Retirement

Social Security

SSI/Disability

Food Stamps/WIC

Other Income

Tithes/Contributions

Rent/Mortgage

Car Payment

Auto Insurance

Auto (Gas & Oil)

Electric/Gas/Water

Food (Groceries & Eating Out)

Phone (Home & Cell)

Cable TV

Day Care

Child/Spousal Support

Furniture/Appliances

Credit Card

School Loans

Bank Loans/Other

Lottery Tickets/Gambling

Personal/Pet Care

Other

Total Monthly Expenses:

Total Monthly Income:

Subtract (-) Total Monthly Expense from Total Monthly Income

What steps are you taking to improve your present situation?

Release Information

I hereby authorize the release of information to Spirit Life Church of Jesus Christ to receive the assistance I am requesting. I further certify the information I have stated is true and correct and that all income is reported. I understand GracePoint may verify the information on this application and that deliberate misrepresentation of information may subject me to denial of assistance/services.

I give permission for Spirit Life Church of Jesus Christ to discuss my case with other agencies,businesses, churches, attorneys, individuals, and any others deemed necessary to verify application information and/or identify additional sources of assistance. I understand that all information will remain as private as possible within these entities.

I have read, understood, and agree to the policies above regarding the Release of Information.

Signature

Benevolence Assistance Request Form

Personal Information

Spouse Information (if applicable)

Applicant Employment History:

Spouse's Employment History:

Additional Information:

Please list 3 References below:

Financial Overview (put "N/A" if a field does not apply to you)

Monthly Income Incurred